An audit made by the National Emergency Laparotomy Audit (NELA) team found that the mortality rate of patients undergoing bowel surgery across England and Wales have reached an alarming number. This is the first time that the quality of emergency laparotomy care was investigated comprehensively across all health care providers/ hospitals.
A set of standards was previously established to guide the overall care of patients recommended for emergency laparotomy. The report made by NELA used these standards as the basis for their evaluation of current hospital practices.
The recommendations are divided into preoperative, intraoperative and postoperative guidelines to safeguard the patients in the entire surgical continuum.
Before surgery, the elements of care include the assessment and creation of a care plan by a consultant surgeon upon the patient's admission, availability of diagnostic evaluation to determine the specifics of the surgery, formal evaluation of death and complications risks, timely administration of antibiotics when infection is suspected and immediate admittance to an operating theatre.
During the surgery, the patient must be directly handled and cared for by a consultant surgeon and a consultant anaesthetist.
After the operation, the guidelines include projected confinement in a critical care unit in cases where patients exhibit a mortality risk exceeding 5 percent and evaluation of patients aged 70 years old and above by specialists of the Medicine for Care of the Older Person (MCOP).
The researchers gathered data from more than 20,000 patients during the first year of data collation, as provided by 192 of the 195 eligible NHS hospitals.
Although there were differences in the data presented by the hospitals, the audit team found that death following bowel surgery is five times higher compared to high-risk elective operations including vascular, cancer and cardiac surgeries.
The key findings in comparison to the set standards prior to surgery include:
Only one hospital appears to have a consultant surgeon review 80 percent of the patients 12 hours after admission. In 49 hospitals (28 percent), only less than 40 percent of the patients were assessed 12 hours after confinement.
Preoperative documentation of death risk was only made in about 56 percent of the patients; 14 percent of hospitals were able to document death risk for at least 80 percent of patients and 22 percent of facilities were able to document death risk in only less than 40 percent of patients.
About 50 percent of patients who presented as an emergency case waited for more than four hours to receive their first dose of antibiotics and 25 percent waited for more than seven hours.
Intraoperative standard for bowel surgery requires the presence of a consultant surgeon and a consultant anaesthetist. NELA found that only about 27 percent of the hospitals had both consultants present in at least 80 percent of the operations. At the minimum, 20 percent of the surgeries in 10 hospitals were carried out without either of the required consultants.
The results of the investigations of postoperative care include:
More than 80 percent of patients in 12 percent of medical facilities were directly transferred to a critical care unit following surgery and less than 40 percent of patients were admitted as recommended in 9 percent of the hospitals.
A specialist from MCOP were only able to assess about 10 percent and 21 percent of elderly patients aged 70 and 90 years old respectively.
As per NELA's recommendation, hospitals should devise a care pathway for all patients, who are candidates for emergency surgeries. These pathways must be specific, noting the time of admission or referrals to another health care team.
The team must give priority to emergency resources and ensure that the entire care process is delivered to every patient. These pathways may also serve as a tool for auditing hence, can also help identify what needs to be improved.
